HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 112 FOSTER STREET 6/24/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record SUN 2 4
Form 4 TpWN OF W) H ANDUvER
R�,�,�1 DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe'used,but the
information must be substantially the two as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location; Left/Right front of house, Rig r hous. , Left/right side of house, Left
Right side of budding, Left/Right front of bu ing, Left of building, Under deck
Address -
-- �-- -- ti� _
Citylrown State Zip Code
2. System Owner.
Name.
Address(if different from location)
crown _ C t `7-1�j Y
Telephone Number
.B. Pumping record
1. Date of Pumping Date Quantity Pumped:
Gauons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
�JeT cue
6. System Pumped By-
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contents-were disposed:
G L S Lowell Waste Water
Sign a Haul pate
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